Summary On 22 April 2006, the general cargo vessel NilsB was unloading a cargo of explosive goods at the Grande-Anse Terminal, Port Saguenay, Quebec, when a small explosion occurred in the lower hold. Two nearby stevedores were taken to the hospital for consultation and then released. There was no damage to the vessel. Ce rapport est galement disponible en franais. Other Factual Information Description of the Vessel The NilsB is a single-deck general cargo vessel capable of loading containers and dry bulk cargo (see Photo1). The propulsion machinery and accommodation are located aft. The vessel, which is strengthened for heavy cargo, has a single cargo hold of 4660m3 grain capacity. The hold is equipped with removable deck panels that serve as a 'tween deck. The vessel also has a pair of 35-tonne cranes on the port side. Grande-Anse Terminal The Saguenay Port Authority (Port Saguenay) manages3 the Grande-Anse Terminal and the cargo handling operation services are provided by Quebec Port Terminals Inc. (stevedoring company). Located between a mountain and the waterfront (see Photo2 and AppendixA), the terminal, which is dedicated to the reception and shipment of general cargo, is isolated from urban areas, with the nearest private building being almost 2km away. Since 1996, the terminal, which has the largest allowable limits for the in transit storage of explosives in Canada4, has seen a five-fold increase in explosives traffic (see AppendixC). The port authority's services are managed by a general director, an administration and operations director, and a director of security, environment, and maintenance. Combined, the three directors possess a comprehensive knowledge of port operations and procedures. They do not, however, possess specific and detailed knowledge of the best practices for the carriage and handling of explosives. History of the Voyage The NilsB was loaded at Papenburg, Germany, and at Varberg, Sweden. Its cargo consisted of 24different kinds of explosive goods5 for a total of 1086.4tonnes- representing a net explosive quantity (NEQ)6 of 962tonnes destined for Canada and the United States. The vessel arrived at the Grande-Anse Terminal, Port Saguenay, at 0550 on 21April2006.7 At 0630, a marine safety inspector from Transport Canada (TC) boarded the vessel to verify its documentation pertaining to the carriage of dangerous goods and to ensure that the onboard fire equipment was ready in case of emergency.8 The TC inspector also verified the fire equipment on the wharf. At around 1030, after checking the unloading operation and the condition of the cargo on the 'tween deck, the TC inspector left the terminal. The vessel was unloaded by two teams of stevedores, with each team comprised of two forklift drivers, a crane operator, and two cargo handlers. Other persons also working in the vessel's vicinity included: two stevedore superintendents, a stevedore manager, and representatives from the charterer and the port authority. In addition to a watchkeeper at the gangway, other crew members performed maintenance duties or were resting. None of the vessel's crew members were assigned to supervise the cargo operation.9 Having received confirmation from the TC inspector that the documents and the safety equipment were in compliance, the port authority representative authorized the unloading of the ship. The cargo operation began at 0800, with the unloading of three containers from the forward part of the cargo hatch covers (see AppendixB for cargo plan). By 0845, the cargo hatch covers were opened and a team of stevedores at each end of the 'tween deck began the unloading. At 1315, forward and aft 'tween deck covers were removed so that unloading could continue from the lower hold. Operations stopped at2100. Operations resumed at 0800 the next day, April22. At approximately 1145, a metal cage was being lowered by the forward crane into the forward section of the hold. When it made contact with the tank top, an explosion took place. The blast displaced the cage approximately 30cm upward and deformed one of the support feet (see Photo3). In addition to the loud noise, shockwave, and smoke, there was a fireball nearly 1m in diameter. A small fire on the deck was rapidly extinguished by a stevedore using a fire extinguisher. The explosion took place approximately 1m from a stevedore who was guiding the metal cage, 2m from a forklift and driver carrying a pallet waiting for the metal cage, and approximately 4m from 20pallets of explosives that had yet to be unloaded. Emergency Response Upon hearing the explosion and seeing smoke from the hold, the port authority representative (who was in his office, some 400m from the vessel), as well as three stevedores on the wharf, the chief officer, and the charterer's representative rushed to the scene. The stevedores in the hold and the crane operator remained at their stations. Some of those who arrived on scene carried portable very high frequency (VHF) radiotelephones. No emergency call was made, nor were any alarms sounded or evacuation orders given. As there were no major material damages or serious injuries, it was deemed to be unnecessary to activate the port's emergency plan. The accident was not reported to the local fire department or Canadian Transport Emergency Centre (CANUTEC).10 Following the explosion, unloading operations were suspended and a search was begun to determine the explosion's cause. Although having numerous years of experience in the handling of explosives, neither the stevedores' manager nor the port authority representative was an expert, and they relied on the charterer's representative to discover the cause. It was concluded that an unspecified cargo had exploded when the metal cage touched the steel deck. The area was swept and plywood placed on the deck where the cage was being lowered. Unloading resumed 30minutes later, in the after end of the hold, and was completed around 1230. Various samples of possible explosive material were collected from the wharf and warehouse, and kept by a representative from Port Saguenay.11 Alerting Authorities NilsB The situation was deemed under control and logged as a small incident by the master. The Canadian Coast Guard's Marine Communications and Traffic Services (MCTS) centre was not informed. Saguenay Port Authority The port authority representative reported the occurrence to a Natural Resources Canada, Explosives Regulatory Division (NRCan, ERD) explosives inspector approximately 45minutes after the explosion.12 The inspector deemed it acceptable that plywood had been installed on the deck and the unloading area had been moved to the after end of the hold, and asked for an incident report. Stevedore Company The stevedores' manager was uncertain how to handle the situation and, at about 1250, he called his company's Occupational Safety and Health (OSH) director located in Trois-Rivires, Quebec, some 300km away, to report the details of the event. To comply with regulations, the OSH director requested that the immediate blast area be secured pending an investigation and/or the possible arrival of potentially interested parties such as TC or NRCan, ERD. At around 1400, it was determined that neither an inspector from NRCan, ERD nor TC would come to the terminal because unloading was complete. The secured area was reopened, and the vessel's cargo hold was subsequently cleaned and readied for the next cargo. Alert and Warning Network System In 2004, to facilitate the task of the alert and warning system (AWS)13 officers, instructions regarding the reporting of transportation occurrences were developed by MCTS, Quebec region, in consultation with TC and the TSB. The instruction package includes, among other things, the following: the definition of a marine accident, marine incident, and other reportable occurrences; a checklist of information that AWS officers are to request from stakeholders; and a list of when and how stakeholders should be advised following a reportable marine occurrence. The instructions stipulate that the TSB, TC, and other stakeholders are to be immediately informed by telephone following any explosion. At 1310, shortly after being informed of the accident by the stevedores' manager, the OSH director informed the AWS of the accident. Because this was the first time the AWS officer had been confronted with such a situation, he called the TC standby manager, triggering a series of calls between TC, the stevedores' OSH director, and the AWS officer. The TC manager and AWS officer concluded that no file needed to be opened for this occurrence. Other interested stakeholders were therefore not informed. On the morning of 24April200614, the TC standby manager informed the TC inspector, who had first inspected the NilsB upon its arrival at Grande-Anse, of the explosion. That afternoon, at 1614, TCofficially notified the AWS. A file was subsequently opened and notification was sent to some 20different stakeholders, including: the Canadian Coast Guard, CANUTEC, Fisheries and Oceans Canada, Environment Canada, Port Saguenay, TC, and the TSB. Communication with these stakeholders was carried out by fax. The TSB received the notification the next morning- on April25- by which time the NilsB had left port. Injuries As a precaution, the two stevedores in the vicinity of the explosion were examined by a physician for potential loss of hearing. Cargo Stowage Explosive material can be sensitive to friction, heat, and impact, and may have substantial destructive potential (see AppendixB). In this occurrence, the three containers on the forward part of the cargo hatch covers, as well as the cargo in the lower hold, were loaded in Germany. The cargo on the 'tween deck was loaded in Sweden. On both decks, a 6m space was left void at each end of the hold, between the cargo and bulkheads, to allow manoeuvring room for forklifts. Loaded to a maximum of two tiers (approximately 2mm high), the cargo from Sweden had been stowed in a compact manner and arrived undamaged: the dunnage and the pallets were solidly set, the deck had no trace of detritus, and the packaging was solid and clean (see Photo4 and Photo5).15 The cargo in the lower hold, from Germany, was loaded in three tiers and reached a height of approximately 3.5m.16 There were indications that the cargo had shifted in the lower hold (see Photo6). Also, the wood planking on some pallets was rotten, and some pallets had missing or damaged flooring. The top of the pallets and the top tank were covered with sawdust and detritus, making it difficult to detect any spilled material. Some packaging was found perforated with cargo spilled on the deck, while other packaging was deformed (see Photo7 and Photo8). Cargo Operations Unloading Because the TSB did not receive notification of the explosion before the NilsB departed the terminal, a visit to the vessel was made in June2006 when it called at the same port with a similar cargo. The practices commonly followed at the Grande-Anse Terminal when unloading explosive cargo are described below. These practices are a combination of those prevalent at the time of the occurrence and measures adopted subsequently in May2006.17 The cargo, which is on wooden pallets, is placed into a metal cage with forklifts. The cage and pallets are then lifted clear by a ship's crane and placed on the dock. A forklift is lowered on both the 'tween deck and in the lower hold at each end once the dunnage is removed. Once there is sufficient manoeuvring space in the hold, two more forklifts are added, accelerating the unloading. At times, forklifts would damage cardboard boxes, spilling explosive material on deck. Up to April2006, there were no measures in place to keep decks clear of small pieces of detritus, and only the larger pieces of dunnage would be removed. By June2006, these practices had been corrected. The forks of the forklifts would occasionally make metal-to-metal contact with the deck. As well, due to the limited space within the hold and the number of forklifts operating inside, the forklifts would come in close proximity to each other while manoeuvring. The metal cages are large enough for two pallets to be loaded side by side. To accelerate the operation, four pallets could be stacked two tiers high. Sometimes, the lower tier would be damaged or crushed by the weight of the upper tier. To facilitate the forklifts' operation and to ensure rapid, uniform, and safe unloading, the metal cage is always lowered in the same area in the hold. To accomplish this manoeuvre while the vessel is rolling- the result of transferring cargo via cranes- the cage is dropped a few centimetres onto the deck. Since the incident, a sheet of plywood has been fitted to the underside of each cage. Once the pallets are on the wharf, forklifts moved them into the warehouse. Pallets would sometimes fall onto the wharf due to the poor quality of the packaging/pallets and their handling. All packaging found to be damaged is replaced by new packaging material shipped with the cargo (when available) or by other boxes that are then hand-labelled. Contrary to the International Maritime Dangerous Goods Code (IMDG Code), however, the repacking is routinely done without using salvage packing18 and without any packing instructions from the box manufacturer. Otherwise, minor damage is often repaired with tape or by covering the entire pallet with wrapping plastic.19 Since May2006, the cargo is now repacked according to the recommendations and under the supervision of the specialist on scene. Equipment The stevedores used metal cages with steel feet, steel hammers and crowbars, standard propane-powered forklifts with steel forks, standard brooms, and dustpans in close proximity to the explosive cargo. Following the May2006 meeting, new procedures govern the use of this equipment. Analysis of Explosive Samples Regardless of whether the spillage occurred after the product left the manufacturer or during loading operations, it was not reported by the stevedores in Papenburg. Upon its arrival inGrande-Anse, packaging was found damaged. Moreover, explosive material was found on board the NilsB and at other locations in the terminal on 22April2006 and again during the TSB visit in June2006. Laboratory analysis revealed that these samples had the potential to detonate if subjected to impact, friction, or heat.20 Regulatory Regime for the Carriage of Dangerous Goods The International Convention for the Safety of Life at Sea (SOLAS) and the International Maritime Dangerous Goods Code (IMDG Code) The IMDG Code was developed under the auspices of SOLAS as a uniform international code for the transport of dangerous goods by sea between states. It covers such matters as packing, container traffic, and stowage, with particular reference to the segregation of incompatible substances. The code became mandatory on 01January2004. Canada's Dangerous Goods Shipping Regulations Prior to 07 June 2007, the Dangerous Goods Shipping Regulations issued under the Canada Shipping Act was the regulatory instrument used to implement the IMDG Code in Canada and meet Canada's obligations under SOLAS. TC Marine Safety Directorate is responsible for administering the IMDG Code in Canada.21 Inspections by the TC Marine Safety Directorate are not mandatory when dangerous goods are being handled. However, marine safety inspectors visit every foreign vessel that calls at a Canadian port to discharge explosives.22 Explosives Act and Regulations Within Canada, explosives are regulated under the Explosives Act. NRCan, ERD administers this act and its regulations. NRCan, ERD inspectors are recognized as the subject matter experts. However, the Explosives Act does not extend to the transportation of explosives23- this is covered by the Transportation of Dangerous Goods Act,1992. Transportation of Dangerous Goods Act, 1992 and Regulations The Transportation of Dangerous Goods Act,1992 applies to the handling and transportation of dangerous goods within and between provinces as well as internationally. Within TC, the Transport Dangerous Goods Directorate works with provincial, territorial, and federal agencies including NRCan, which is responsible for issues concerning explosives and the Canadian Nuclear Safety Commission. In addition, it works with TC's Marine Safety Directorate, which is responsible for administering the Transportation of Dangerous Goods Regulations (TDG Regulations) and the IMDG Code in Canada. Memoranda of agreement have been signed with each province and territory on matters of regulatory compliance involving the highway movement of dangerous goods. These memorandums enable TC to direct its enforcement efforts towards the transportation of dangerous goods by air, rail, and sea. The regulations are referenced or adopted by all provinces and territories. The Transport Dangerous Goods Directorate is involved in the development of international rules and standards through the United Nations. Its program is harmonized or aligned with international and United Nations recommendations and United States requirements. The Transport Dangerous Goods Directorate includes CANUTEC, which provides a 24-hour, 7days per week emergency advisory and regulatory information service. Interface between the IMDG Code and the TDG Regulations The TDG Regulations apply to the marine transportation of dangerous goods (other than in bulk) between two places in Canada. Furthermore, the TDG Regulations require that transportation of dangerous goods, between Canada and another country (except an inland voyage) or between two points in Canada on a Home Trade Voyage Class1, shall comply with the IMDGCode. In the case of explosives unloaded in Canada by a ship engaged in an international transportation, the IMDG Code applies until the cargo lands on the dock apron, when it becomes subject to Canada's TDG regulatory regime. Canada's Ports Regulatory Regime Federally owned ports in Canada are regulated by the Canada Marine Act. Most are classified as Canada Port Authorities (CPAs) which are autonomous bodies with their own letters patent. TC has retained direct authority over a limited number of public ports, most of which are in remote locations. Port Saguenay is a CPA and manages the Grande-Anse Terminal. Regulations issued under the Canada Marine Act include the Port Authorities Operations Regulations for CPAs and the Public Ports and Public Port Facilities Regulations for public ports. These regulations include references to dangerous goods and emergency situations. Some CPAs have issued their own regulations and guidelines that further define procedures and responsibilities with respect to dangerous goods; Port Saguenay has not. Governance of Terminals Many CPAs own and develop marine terminals. In larger ports, it is normal practice for cargo terminals to be leased out to terminal operators for lengthy periods. The authority (usually described as a "landlord" port) then exercises control through the terms of the lease and any applicable port regulations, by-laws, or guidelines. Other authorities have chosen to be "operating" ports and to manage the terminal themselves. In this latter case, authorities enter into arrangements with ship/cargo interests and employ stevedoring companies to handle the cargo operations. Port Saguenay is the manager of Grande-Anse Terminal and the cargo handling operation services are provided by Quebec Port Terminals Inc. Handling Explosives in Canadian Ports Larger ports in Canada have developed in-house expertise on the handling of dangerous goods, including explosives cargo.24 This allows for effective oversight and ready access to authoritative resources. Smaller ports- such as Port Saguenay- that do not have in-house expertise rely on the proactive involvement of TC Marine Safety and Transport Dangerous Goods directorates, NRCan, ERD, plus the expertise available from the local terminal operator or stevedores, as well as the shipper or receiver of the explosives. IMO's Recommendations on the Safe Transport of Dangerous Cargoes and Related Activities in Port Areas The IMO provided a set of recommendations for the handling of dangerous cargoes within port areas through Maritime Safety Committee (MSC) Circular675, Recommendations on the Safe Transport of Dangerous Cargoes and Related Activities in Port Areas.25 These recommendations address issues such as training, stakeholders' shared responsibilities, and the handling of dangerous goods while within the port area. The document includes guidance on handling Class1 explosives- specifically covering loading, handling, equipment, cleanliness, and fire precautions. The document proposes the naming of responsible persons for various situations and lists selection criteria (See AppendixF). Assessment of Quantity Limitations - Distance for Explosives In Canada, the interdepartmental Technical Committee on Dangerous Goods surveys and evaluates the various terminals for their suitability to handle explosives and, if suitable, establishes the quantity of explosives allowable. This process and its results were not incorporated into any regulation at the time of the occurrence; however, the outcome was regarded by the port authorities as binding.26 AppendixE presents the results of the evaluation of the Grande-Anse Terminal on 25June2003. Training, Certification, and Experience In accordance with the TDG Regulations, the stevedoring company gave training to all staff working with dangerous goods.27 The course material included information on the nature of dangerous goods and their safe handling. It also included general information on the precautions to be taken when dealing with dangerous materials and specifically those likely to be encountered at Grande-Anse, such as explosives. Finally, it included information on the importance of establishing and following an emergency plan. In terms of on-the-job experience, most stevedores had over five years of experience handling explosive cargos and some had over 25years of experience in handling general cargo. The charterer's representative had nearly 20 years of experience working with explosive cargo. This included being responsible for the logistics of receiving orders from firms in Canada and the United States, collecting the goods in Europe, chartering the vessels, and shipping cargo from ports to consignees. Both the master and the chief officer held certificates of competency for the service and voyage on which the vessel was engaged. Both had also taken dangerous goods training and were certified accordingly. On several previous occasions, the crew of the NilsB had transported dangerous goods. Safety Management and Emergency Planning NilsB The NilsB was employed to carry explosives between Europe and Canada under a time charter. The charter party defines the responsibilities of the operator and the charterer. Under this arrangement, the vessel must be presented in good condition and duly certified. This responsibility is not limited to the vessel's operator, but also includes the master and crew, who must ensure the vessel's seaworthiness, proper cargo stowage, and certification compliance. The charterer is responsible for cargo handling at both ends of the voyage. Whether the bills of lading for the cargo were annotated (claused) by the master as to condition on loading is unknown. The International Safety Management (ISM) Code provides for safe practices in ship operation and a safe working environment, establishes safeguards against all identified risks, and seeks to continuously improve the safety management skills of personnel ashore and aboard ships, including preparing for emergencies. The ISM documentation of the NilsB, concerning the carriage of dangerous goods, is limited to the following reference: ...Cargo operations are subject to SOLAS ChapterVI. For particular cargoes, the relevant regulations are to be observed (e.g., Dangerous Goods Code, Code of Safe Practice for Solid Bulk Cargo)... The master had no specific instructions concerning explosive cargo; for example, information on tools and equipment to use, handling operations, stowage and securing of goods, and surveillance during the voyage. Emergency schedules that are found in the IMDG Code and which are specific for each dangerous good- and could have guided the master- were on board but not readily available. On the NilsB, the chief officer is responsible for cargo operations. During the TSB's June2006 call at Grande-Anse Terminal, he was not always aware of cargo damage and he did not regularly monitor unloading operations. This was left to the stevedores' superintendent and the charterer's representative. The latter divided his time supervising both the vessel's unloading operations and road shipments. Saguenay Port Authority The port authority has its own emergency management plan that gives general information about the port and its administration, and identifies the roles and responsibilities of stakeholders (internal, municipal, provincial, federal, and private). The plan includes communication procedures, a telephone directory, an intervention strategy for various emergencies, and required training for different stakeholders. One aspect of the emergency management plan covers fire or a spillage of explosives. In the event of spillage, the plan states that: explosive material is not to be touched or stepped on; all possible sources of ignition (cigarettes, sparks, flames) are to be eliminated; radios are not to be used within 100 m of any electric detonator; CANUTEC is to be called and the situation is to be evaluated for fire, for risk to people and property, required material, and human resources; and the fire department is to be alerted, if necessary. In the event of a cargo fire, the plan states that: the area is to be evacuated to a minimum distance of 1600m; any vehicle or cargo that has been exposed to fire is not to be moved; and the fire department, CANUTEC, and local residents are to be informed. The emergency management plan contains no contingency for explosions. Fire Suppression System on the NilsB The Document of Compliance for the carriage of dangerous goods, which is mandatory, states that the NilsB may, under certain conditions, carry explosives.28 One condition is that Class1 explosives must be stowed within range of the sprinkler system placed under the cargo hatch covers. Stowing any cargo in the lower hold would therefore require that the panels that comprise the 'tween deck remain open throughout the voyage. In both April and June2006, it was observed that the removable 'tween deck panels were closed. This would have prevented water from the vessel's sprinkler system from reaching cargo stowed in the lower hold. 'Tween Deck Hatch Covers After completion of loading the lower hold at Papenburg, the crew installed the four 'tween deck covers so that loading could take place on top of the panels at Varberg. After completion of discharge of the 'tween deck at Port Saguenay, the crew removed these same panels so that cargo in the lower hold could be accessed for discharge. In both instances, these deck covers were being handled directly over explosives that had the potential to explode upon impact.